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2014 PPE Disclosure Statement It is the policy of the Oregon Hospice Association to insure balance, independence, objectivity, and scientific rigor in all its educational programs. All faculty participating in any Oregon Hospice Association program is expected to disclose to the program audience any real or apparent affiliation(s) that may have a direct bearing on the subject matter of the continuing education program. This pertains to relationships with pharmaceutical companies, biomedical device manufacturers, or other corporations whose products or services are related to the subject matter of the presentation topic. The intent of this policy is not to prevent a speaker from making a presentation. It is merely intended that any relationships should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. This presenter discloses these relationships: Salix Pharm – speakers bureau and scientific advisory board; Grant Funding – AHRQ, CMMI, NINR, The Duke Endowment: Aspire Health – Senior Medical Advisor 1

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Secondary Diagnosis Wanted! 67% all claims Only report primary diagnosis “The reporting of only one principal diagnosis does not lend to a comprehensive, holistic, and accurate description of the beneficiaries’ end-of-life conditions and may not fully reflect the individualized needs in the individual’s required hospice plan of care.” FY 2013 Data

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Use of Nonspecific Symptom Codes o Cannot use any “ill defined diagnosis” as a principle diagnosis (780-799) o Can no longer use debility and FTT - MACs will soon be instructed to return claims for more definitive diagnosis, RTP by Oct 1, 2014 o ICD-9-CM does not allow use of nonspecific codes as principal diagnosis

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Manifestation Codes o Manifestations are characteristics, signs or symptoms of an illness. When one disease or condition causes another disease or condition, the one that caused it is the etiology and the resulting second condition is the manifestation. o Manifestation codes cannot be principal diagnosis

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Choosing Diagnosis “It is often not a single diagnosis that represents the terminal illness of the patient, but the combined effect of several conditions that makes the patient’s condition terminal.”

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Do not include comorbidities that do not contribute to the terminal prognosis in the narrative!

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Let’s look at a tougher case.. 94 yo WF with mild dementia, osteoporosis, and hypothyroidism. She has been to the ER for falls x 3, sustained a wrist fracture. PPS 60 to 40%, weight loss of 10 pounds with BMI of 19. Only eating 20%, 3/6 ADLs. Do you admit? If so, diagnosis, principal dx? Secondary dx?

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Choose the best diagnosis o Principal Dx – Osteoporosis o Secondary Dx – Wrist fracture, FTT o What about Dementia? Hypothryoidism? This question was posed to one of the MACS who confirmed osteoporosis as principal dx

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What if only diagnosis ill-defined? 77 year old patient with dysphagia, decreased oral intake, malnutrition with albumin of 2.1, weight loss 10 pounds in 6 weeks with BMI of 17.6. PPS 60 to 30% in 1 month timeframe. No underlying diagnoses or comorbidities. Doesn’t want to return to ER or hospital. Prognosis determined by physician to be < 6 months.

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How to Code? o Malnutrition – 263.9 o Dysphagia – 787.20 o Muscle weakness – 728.87 This example given in the Final Rule. Only use ill defined if NO other principal diagnosis relevant

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Example of Certification 77 yo WF with principal diagnosis of protein calorie malnutrition (263.9)* and related diagnosis of and failure to thrive (783.7), weight loss, (783.21) and dysphagia. ( 787.21) No other comorbidities. PPS has declined from 60% to 30%, and now dependent on all ADLs. Refuses further hospitalizations or ER, with goals focused on comfort care. * Codes not needed

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Coding Guidelines o Malnutrition o Abnormal weight loss “ According to ICD 9 Coding Guidelines, codes that fall under the classification “Symptoms, Signs, and other Ill-defined Conditions”, such as “debility” and “adult failure to thrive”, can only be used as a principal diagnosis when a related definitive diagnosis has not been established or confirmed by the provider.” Answer to question posed in Final Rule

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But wait! – haven’t the MACs encouraged use of FTT/Debility? o Palmetto MAC – specific LCD on FTT o Furthermore they state In the event a beneficiary presenting with a nutritional impairment and disability does not meet the medical criteria listed above, but is still thought to be eligible for the Medicare Hospice Benefit, an alternate diagnosis that best describes the clinical circumstances of the individual beneficiary should be selected (e.g. 783.21 "abnormal loss of weight" and 799.4 "Cachexia”) http://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx

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What about NGS? o Decline in clinical status o PPS <70% 2/6 ADL dependence o NGS - Contractors will not make any changes to the edits until we receive direction from CMS in the form of the Change Release Published: May 30, 2013

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New Patient Admissions o Avoid ill defined primary diagnosis if at all possible o Use LCDs for guidance o Include ALL diagnosis affecting prognosis on claim form and in narrative o Medication profile may be helpful in determining diagnosis o Narratives should reflect WHY you are admitting this patient. If patient does not meet LCDs then explain what is causing the < 6 month prognosis

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Existing Debility/FTT Patients o Physician – review plan of care and note affected bodily systems, symptoms, and medications o Change to more appropriate diagnosis based on above with use of multiple secondary diagnosis to support o Write order to change diagnosis and document reason for change o Adjust medications covered

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Comprehensive Assessment o Determined by the IDG o Related and unrelated diagnosis incorporated into plan of care o Should be an ongoing process when new diagnosis are added

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Here’s the Confusion... o According to CMS claims manual, “the principal diagnosis is defined as the condition established after study to be chiefly responsible for the patient’s admission” o But the manual also says to follow ICD -9 coding guidelines. o Hospices generally list ESRD is the cause for the patients limited prognosis and use the LCD to support

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What does CMS say? o Use ICD 9 guidelines o Hence in this case you would pay for the insulin/diabetes care and renal medications

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What’s the Impact? o Medication and treatment costs likely to rise as more diagnosis are captured as secondary o Required to pay for all primary and secondary diagnosis

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Proper Coding o HMD/staff physicians – understand basics – buy ICD manual o Do not use manifestation codes o Follow proper sequencing o Do not use mental codes 290-319 o Do not use ill defined dx 780-799 o Be as specific as you can in explaining diagnosis so coders can code accurately

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Related VS Unrelated It is our general view that … “hospices are required to provide virtually all the care that is needed by terminally ill patients” (48 FR 56010 through 56011). Therefore, unless there is clear evidence that a condition is unrelated to the terminal illness, all services would be considered related. It is also the responsibility of the hospice physician to document why a patient’s medical need(s) would be unrelated to the terminal illness prognosis.

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Related vs Unrelated Multiple interpretations as to the meaning of what are considered ‘‘related conditions” “Our expectation continues to be that hospices offer and provide comprehensive, virtually all-inclusive care.”

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Related Treatments o Unless clear evidence that a condition is unrelated to the terminal illness, all services would be considered related. o Physician needs to justify why a diagnosis is not being covered! o Must be documented!

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Question asked to CMS – 8/13 o Principle dx – COPD o Comorbidities - coronary artery disease and Parkinson's disease Doc stated unrelated to COPD and would only cover meds/tx for COPD CMS – this does not encompass holistic nature to exclude other conditions. Reiterated hospice should provide “virtually all the care.” Must be clear evidence as why it’s not related

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CMS goes on to say….. o We have previously acknowledged that there are those rare circumstances in which a service may not be related to the patient's terminal prognosis and that this determination is to be done on a case-by-case basis by the hospice physician with input from the IDG.

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Medication Costs Hospice Cost Report Data Are hospices paying for all necessary related medications? Why the decline? Is Part D taking the brunt of these payments? Where are your perdiem costs?

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Final Rule o Cover all symptom meds – acute or chronic o Used to be considered an inducement to pay for unrelated drugs o How are hospices handling this?

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Department of Health and Human Services - Office of Inspector General o “Medicare Could Be Paying Twice for Prescription Drugs for Beneficiaries in Hospice” - June 2012 http://oig.hhs.gov o Objective: To determine whether Medicare Part D paid for prescription drugs that likely should have been covered under the per diem payments made to hospice organizations.

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Strategies to Combat Costs o Educate physicians on accurate coding diagnosis that relates to prognosis o Develop standardized forms to help with processes of coverage determination o Work with PBM to obtain lower costs o If not using – develop formulary o Consider pharmacist to review meds and make recommendations o Pay attention to response from MAC

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Attending Physician - Risks o Hospice changes patient’s AOR when moved to an IPU for GIP, often to a NP o Hospice “assigns” a AOR o Hospice does not get signature of AOR on the initial certification At risks for survey deficiencies or non- compliance audits

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AOR Changes o “Change in Attending” form required Includes physician’s full name Address and NPI number Effective date Date statement signed Patient/representative sig Acknowledgment choice of patient

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Team Effort Across Departments o Collaboration necessary to identify systems impacted o Across clinical, financial and IS areas o Include HIM o IT – databases and necessary software o Administration support necessary

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Notice of Election/Revocation o Both Notice of Election (NOE) and Notice of Termination/Revocation/ (NOTR) – submitted within 5 days o Risk Area Not having full proof process set up to capture. If late – no payment (similar to F2F)

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Discussion o Great variation among hospices regarding related diagnosis and medications. How do you standardize this in your organization? o Need to develop processes to coordinate physician/admissions/coder